Payment Page

Customer #

Amount

$

Credit Card Surcharge

Total

To cover the cost of accepting credit cards, we will collect a 3% credit card surcharge.

***Manually enter all fields below. AUTOFILL WILL RESULT IN ERROR!

Patient Name

Patient DOB

Payment Info

Payment details

Card Number

Expiration Date

Security Code (CVV)

MasterCard

Billing Info

First Name

Last Name

Address 1

Address 2

City

State

Zip/Postal Code

Country

Email Address

Phone #

Click here to make a payment